National Initiative Strives to Reduce Surgical Site Infections
By Kelly M. Pyrek
Perioperative infections complicate an estimated 2.6 percent of nearly 30 million operations annually, resulting in approximately 780,000 surgical site infections (SSIs).
Tried-and-true methods of preventing these SSIs with a particular emphasis on the administration of antimicrobial surgical prophylaxis are being supported by the work of a number of physicians, nurses and infectious-disease experts from the entire healthcare continuum. Their efforts to reduce the 40 percent to 60 percent of preventable SSIs have culminated in the Surgical Infection Prevention project (SIP), a national quality improvement initiative launched two years ago and co-sponsored by the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC). SIP is conducted through the CMS Health Care Quality Improvement Program, and its goal is to reduce the occurrence of post-operative infection by improving the selection and timing of preventive antibiotic administration.
In June, the authors of all current U.S. surgical infection prevention guidelines, along with professional organizations that are involved in surgical care, released a joint advisory statement on infection prevention, Antimicrobial Prophylaxis for Surgery: An Advisory Statement from the National Surgical Infection Prevention Project.
This advisory statement is the result of a year-long effort by leading national medical organizations to identify best practices for preventing surgical site infections, says Peter Houck, MD, leader of Medicares National Surgical Infection Prevention Project. We are pleased that this statement has been accepted by more than 20 medical societies and national healthcare organizations.
Participating organizations were American Academy of Orthopaedic Surgeons, American College of Obstetricians and Gynecologists, American College of Surgeons, American Geriatrics Society, American Society of Health-System Pharmacists, Infectious Diseases Society of America, The Medical Letter, Society of Thoracic Surgeons, Surgical Infection Society, Society for Healthcare Epidemiology of America, and VHA, Inc.
Representatives of these and other organizations serve on the projects expert panel. The expert panel meets monthly to provide clinical expertise and support to the CMS/CDC steering committee on project features, such as operations/procedures, quality indicators, support and collaboration. The expert panel is comprised of leading infectious disease and surgical experts representing more than 16 national organizations.
When SIP was launched in 2002, clinical experts identified areas of inconsistency among the existing surgical infection prevention practice guidelines, as well as issues that were not addressed in any of the guidelines. Areas of focus included selection of antibiotics for patients with certain antibiotic allergies, and the duration of antibiotic therapy after completion of the operation.
Project leaders hosted a forum of national medical organizations in January 2003 which led to initial consensus regarding antibiotic selection, timing, and duration for certain surgeries. The resulting advisory statement was accepted by all of the participating organizations, as well as additional national medical organizations. The principle concepts coming out of this forum were recommendations that antibiotics used to prevent surgical infection should be given during the hour before surgery and that they should not be used for more than 24 hours after the end of the operation. Timely administration results in more effective infection prevention, while short duration is less likely to produce antibiotic-resistant bacteria, experts concurred.
Optimal prophylaxis ensures that adequate concentration of an appropriate antimicrobial are present in the serum, tissue, and wound during thee entire time that the incision is open and at risk for bacterial contamination, Bratzler and Houck1 write. The antimicrobial should be active against bacteria that are likely to be encountered during the particular type of operation being performed and should be safe for the patient and economical for the hospital. The selection and duration of antimicrobial prophylaxis should have the smallest impact possible on the normal bacterial flora of the patient and the microbiologic ecology of the hospital.
One of the things we identified very early in the process of developing the SIPP was the fact there were quite a few different guidelines for antimicrobial prophylaxis, and we wanted to achieve consistency, says Dale Bratzler, DO, of the Oklahoma Foundation for Medical Quality. To some extent, our goal was to simplify the guidelines, get the authors of the guidelines together, and in the process of reviewing the literature and talking about the guidelines, we might develop some consensus and consistency in the guidelines as they were updated. That has definitely happened.
Most importantly, SIP addresses the need to translate clinical research into real-world practice.
I think translating research into practice is a key issue, Bratzler says. As I travel the U.S. speaking about SIP, I frequently point out that the original data (suggesting administering the first antimicrobial dose within the hour before surgical incision) was first published in 1957; it has taken 40 years to get that evidence into practice. And were still not there. Its critical to take evidence from clinical trials and then get hospitals and operative teams to apply it to practice. He continues, Its not easy work. In our audit, more than 99 percent of the patients got an antibiotic dose; the doctors almost never forgot to give one, but the timing was not good. Only about 60 percent of patients got their .rst dose within an hour before the incision. Its all about empowering someone to make sure the antibiotic is turned on within that hour before incision. Its not that people dont understand and recognize theres real benefit from antimicrobial prophylaxis, but the challenge is putting the system in place to make sure it happens with every patient.
To that end, a number of hospitals have created regional SIP collaboratives. One of the most successful has been the Surgical Infection Prevention Collaborative Northwest (SIP NW) in which 11 Washington state hospitals have worked for the past year to reduce their SSI rates. The major goals of the SIP NW have been the proper administration of antibiotics, along with clipping not shaving the surgical site, and maintenance of proper body temperature before and after surgery.
At the 240-bed Overlake Hospital Medical Center in Bellevue, Wash.:
- 100 percent of all surgical cases received an appropriate selection of antibiotic prophylaxis
- 75 percent of patients received antibiotics within an hour before surgical incision
- 97 percent of patients who received antibiotics had those medicines discontinued within the appropriate 24-hour period after surgery
- 72 percent of surgical patients had a temperature greater than 36 degrees Celsius
- 88 percent of surgical patients had their hair removed at the surgical site without shaving
According to the summary report for the SIP NW Outcomes Congress, in 2002, Overlake had 12 SSIs, and in 2003, that number was reduced to five, equating to a cost savings of $39,000.
At the 142-bed St. Marys Medical Center in Walla Walla, Wash.:
- Appropriate antibiotic prophylaxis was administered to 100 percent of eligible patients in the pilot group
- The proportion of patients receiving antibiotic prophylaxis within one hour before surgical incision was increased from 74 percent to 100 percent
- The percentage of surgical patients with antibiotics discontinued within 24 hours after surgery went from 70 percent to 92 percent
- The proportion of patients demonstrating minimal heat loss went from 25 percent to 92 percent
- The proportion of patients undergoing appropriate hair removal at the surgical site changed from 10 percent to 80 percent
St. Marys summary report said, Changes in the perception of acceptable rates of infection have shifted to zero. There are no acceptable rates of healthcare-associated infections.
As Ive traveled across the country, Ive seen a wide mix of hospitals participating in these local and regional collaboratives, Bratzler says.
There is a lot of excitement around the collaborative process, bringing people together for the common cause of fighting SSIs. In Oklahoma, we started our collaborative on surgical infection prevention and marketed it to infection control practitioners (ICPs) and operative teams, not necessarily the same audience we usually would use for most of our quality improvement projects. We targeted ICPs because we thought they were very important in terms of helping the hospitals take action on some of these performance measures. I think getting ICPs involved is the way its been across most of the country.
Houck says ICPs passion about the project is contagious. I spoke at the annual APIC meeting again this year and I was very impressed with their enthusiasm. A lot of them were already working on SSI-prevention projects, and many of them were participating in a SIPP collaborative. I thought there was a terrific amount of energy there. The infection control community really sees SIP as a way to prevent infections as well as a way to get into the healthcare quality-improvement world. Its no surprise, since often times, ICPs are the ones who actually are effecting change at their facilities. Physicians will be involved, but it seems to me, the nurses are actually spearheading the projects.
Bratzler concurs. The vast majority of surgeons are ordering antibiotics, but we know they are not being given at the appropriate time; weve seen operative teams take ownership of the fact they need to put the systems into place, he says. Whether its the surgeon, or someone else from the OR staff, somebody has to take the responsibility of ensuring that the antibiotics get administered. In the infection control community, most already have an ongoing program for surveillance for SSIs, and many of them are doing things beyond what were looking at in the national project, other things that reduce infection rates. ICPs have a key role in terms of their ongoing surveillance.
The next phase of the national initiative, called the Surgical Care Improvement Project (SCIP), is under development, according to Bratzler and Houck. SCIP is a broad coalition of partners focused on improving surgical care in the U.S. through the prevention of complications associated with surgery.
SCIP will take the measures we have been using for SIP, which are entirely for antimicrobial prophylaxis, and expand them to address a number of post-operative complications such as acute myocardial infarction or post-op pneumonia, Houck says. Through SCIP, we will continue to work on SSIs, but the scope of what were going to address will expand considerably.
Houck estimates that SCIP will be ready by the fall of 2005, and currently, the group is working on establishing performance measures, collecting data, and coordinating activities of all of the partners.
Whats so exciting about SCIP is the intense and intimate participation by all the organizations, as well as the spread of the work outside the Medicare population, Houck adds.
For more information about the National Surgical Infection Prevention Project, go to www.medqic.org/sip.